Combined hepatocellular cholangiocarcinoma in hepatectomy specimens: A clinicopathologic analysis

Background

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is an uncommon form of primary liver carcinoma. It is heterogenous in terms of morphology, immunohistochemistry, radiology, and clinical features; making it a challenging entity for diagnosis.

Aims

The purpose of the present study was to evaluate clinicopathological characteristics of patients with cHCC-CCA.

Settings and Design

Retrospective observational study.

Materials and Methods

The patients diagnosed with cHCC-CC were identified from hepatic surgical specimens and were evaluated.

Statistical Analysis

Survival was estimated as per Kaplan-Meier method.

Results

Out of six patients, five had undergone resection while one had liver transplant. Five were male and one was female and the mean age was 52 years. Tumor markers revealed raised serum alfa-fetoprotein and CA19.9 in four and three patients, respectively. Five of the liver specimens were cirrhotic. Diagnosis was predominantly based on tumor morphology. All cases were of Allen and Lisa type B and cHCC-CCA as per WHO (2019) classification. Stem cell features <5% were noted in two cases. Immunohistochemistry for programmed death 1/programmed death ligand 1 (PD1/PDL1) was negative in both the hepatocellular and cholangiocellular components in all six cases. Mismatch repair (MMR) protein expression was retained in two and deficient in four cases. The median follow-up after surgery was 21.3 months (range, 5-46.2 months). Five patients had intrahepatic and/or extrahepatic recurrence on follow-up after surgery. The median recurrence-free survival was estimated at 13.1 months (95% CI 5.67-20.6). Three patients had received salvage treatment. The median overall survival was estimated at 20 months (95% CI 0-45.3).

Conclusions

The present study highlights the role of morphology in the diagnosis of cHCC-CCA. The choice of locoregional and/or systemic therapy after surgery may be individualized based on the clinicopathological characteristics.

The Demographic and Clinicopathological Characteristics of Hepatopancreatobiliary Cancers From a Specialized Center in India

Introduction Hepatopancreatobiliary (HPB) cancers are a distinct group requiring specialized multidisciplinary care. The present study was an analysis of HPB cancers. Methods The institutional data for two years from 2017 to 2018 was retrieved from the hospital-based cancer registry (HBCR) database in Excel format (Microsoft® Corp., Redmond, WA). The demographic details, method of diagnosis, tumor characteristics, and disease extent of the patients with HPB primary sites were retrospectively analyzed. Results Out of the 1417 patients with HPB malignancies, 1193 were analyzed. Most of the patients at our center hailed from North India. The distribution of HPB cancers was as follows: hepatocellular carcinoma (HCC) (n=717, 60.1%), gallbladder (GB) (n=230, 19.3%), periampullary carcinoma (n=76, 6.37%), head of the pancreas (HOP) (n=55, 4.61%), extrahepatic bile duct (EBD) (n=53, 4.44%), intrahepatic bile duct (IBD) (n=32, 2.68%), and body of the pancreas (BOP) (n=30, 2.52%). The most common disease presentation of HPB cancers was in the seventh and sixth decades of life. Male predominance was seen in all HPB cancers except in GB with a higher incidence in females. The predominant cause of chronic liver disease (CLD) with HCC was viral-related (53.7%) with hepatitis B virus (HBV) (34.3%) higher than hepatitis C virus (HCV) (19.2%) followed by non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) (24.8%) and then alcohol. Adenocarcinoma was the most common morphology in pancreatobiliary malignancies. The disease presentation was locoregional in 63.4% of HCC, 69.7% of periampullary carcinoma, and 50.9% of HOP cases. The patients with EBD and IBD cancers presented commonly with locoregional disease extent in 60.4% and 62.5%, respectively. Perihilar subsite was more commonly detected (71.7%) as compared to the distal one in the patients with EBD cancers. The patients with GB cancers (GBC) presented with distant metastases in 53.5% and locoregional disease in 33%. Distant metastases were present in 76.7% of the patients with BOP cancers. The liver was a common site of distant metastases in GB, periampullary, and pancreatic cancers. Conclusions The present study highlights the characteristics and the variations in disease presentation in different primary tumor sites of HPB cancers. In view of the common locoregionally advanced disease presentation of HCC, the patients with CLD need surveillance for the early detection of lesions. As the patients with HPB cancers show advanced disease presentation, effective locoregional and systemic therapies are needed.

Epidemiologic Study of Patients Registered in Oncology Unit at a Hepatobiliary Tertiary Care Center in India

Background: Cancer accounts for about 1 in 7 deaths, worldwide. Primary cancers of the hepatobiliary system are significant health problems worldwide and their management presents great challenges for the hepatobiliary specialist. The incidence of hepatobiliary malignancies is on an increasing trend in India. Study: We did a retrospective study for the epidemiologic, clinical characteristics, and outcomes of patients with cancer registering for treatment in the oncology division at the Institute of Liver and Biliary Sciences, Delhi, India, between January 1, 2017 and December 31, 2017. Results: Atotal of 502 new patients were registered during the study period. The majority of the patients were male (M:F 1.69:1), in the age group of 35–64 years (64.3%) and presented in advanced stages of the disease (72.7% in Stage III and IV). The most common cancers were gallbladder cancer (GBC) (29.7%) and hepatocellular carcinoma (HCC) (17.3%). GBC was the most common in females (M: F 1:1.6), 86.6% were advanced (Stage III and IV), and gallstones were present in 44.3% patients (M: F 1:2.9). Periampullary carcinoma presented in early stages (71% in Stage I and II). Survival at 6 months (n = 110 evaluable patients) was 100% for Stage I, 88% for Stage II, 73.7% for Stage III and 42.1% for Stage IV, and 62.7% overall (P < 0.001). Survival at 6 months (n = 123 evaluable patients) was 56.5% for biliary cancers, 71.4% for HCC, and 75% for nonbiliary cancers (P = 0.15). 217 (43%) patients had one visit to the hospital and 168 (34%) patients had 2–5 visits with no or little follow-up. Conclusions: Most of the disease burden was in the male gender (GBC was more common in females), in the age group 35–64 years and with advanced disease presentation (except periampullary cancer). Survival diminished significantly with increasing stage of disease. Survival was worse for patients with biliary cancers. This could be due to advanced presentation, poor follow-up, and inadequate public health awareness.

External radiotherapy and brachytherapy in the management of extrahepatic and intrahepatic cholangiocarcinoma: available evidence

This review aims to summarize the currently available evidence for the role of external radiotherapy and brachytherapy in the management of cholangiocarcinoma. High locoregional disease recurrence rates after surgical resection alone for both the extrahepatic cholangiocarcinoma (EHCC) and intrahepatic cholangiocarcinoma (IHCC) provide a rationale for using adjuvant radiotherapy with chemotherapy. We performed a literature search related to radiotherapy in cholangiocarcinoma published between 2000 and 2016. The role of radiation is discussed in the adjuvant, neoadjuvant, definitive and the palliative setting. Evidence from Phase II trials have demonstrated efficacy of adjuvant chemoradiation in combination with chemotherapy in EHCC. Locally advanced cholangiocarcinoma may be treated with neoadjuvant chemoradiotherapy. In the case of downsizing, assessment for resection may be considered. Brachytherapy offers dose escalation after external radiotherapy. Selected unresectable cases of cholangiocarcinoma may be considered for stereotactic body radiation therapy with neoadjuvant and/or concurrent chemotherapy. Liver transplantation is a treatment option in selected patients with EHCC and IHCC after neoadjuvant chemoradiation. Stenting in combination with palliative external radiotherapy and/or brachytherapy provides improved stent patency and survival. Newer advanced radiation techniques provide a scope for achieving better disease control with reduced morbidity. Effective multimodality treatment incorporating radiotherapy is the way forward for improving survival in patients with cholangiocarcinoma.

Development of a novel recombinant LHRH fusion protein for therapy of androgen and estrogen dependent cancers

LHRH based vaccines are promising candidates for therapy of androgen and estrogen dependent cancers. We report in this communication development of a novel recombinant protein vaccine candidate against LHRH. A synthetic gene was designed in which the codon sequence in the LHRH decapeptide was modified by substituting the codon for 6-glycine with that of l-leucine. Further the LHRH(6leu) gene was linked to heat-labile enterotoxin of E. coli (LTB) as carrier. This LHRH(6leu)-LTB gene was cloned into a prokaryotic expression vector under the control of inducible and strong bacteriophage T7 promoter to over-express LHRH(leu) fused to LTB as recombinant protein in E. coli. Recombinant LHRH(leu)-LTB protein of ∼14 kDa size, was purified from inclusion bodies using in-situ refolding on the column and Ni-NTA based immobilized affinity chromatography. Western blot confirmed the immunoreactivity of purified LHRH(leu)-LTB fusion protein with anti-LHRH monoclonal antibody. The vaccine protein was further characterized by mass spectroscopy, circular dichroism and fluorescence spectroscopy. This communication reports a recombinant LHRH fusion protein with potential for blocking of sex hormones production for eventual therapy of sex hormones dependent neoplasms.

Clinical outcome and morbidity in pediatric patients with nasopharyngeal cancer treated with chemoradiotherapy

OBJECTIVES

The aim of the study was to evaluate the outcome and treatment-related morbidity in pediatric patients with nasopharyngeal carcinoma (NPC) treated with chemoradiotherapy.

METHODS

We did a retrospective review of 41 pediatric patients diagnosed with NPC between 2000 and 2013. The majority of the patients were treated with neoadjuvant chemotherapy followed by concurrent chemoradiation with the dose of 70 Gy in 35 fractions. Eight patients were treated with intensity-modulated radiation therapy, while the remaining with three-dimensional conformal radiation therapy or two-dimensional simulation technique.

RESULTS

The median age of the patients was 14 years (range 6-20 years). Most of the patients had locoregionally advanced disease (stage III/IVA/IVB). The histology of all the cases was undifferentiated carcinoma. Immunohistochemistry for the Epstein-Barr virus-Latent membrane protein 1 was positive in nine of the 13 tested cases. The median follow-up for all and the surviving patients was 26.6 months (range 2-140.8) and 51.2 months, respectively. The 3-year overall survival (OS) and event-free survival (EFS) rates were estimated at 83.7% (95% confidence interval [CI]: 64.8-93%) and 55.8% (95%CI: 38.7-69.8%), respectively. Distant metastases were the predominant pattern of failure. Treatment response showed an independent association with OS. T classification (T1/T2 vs. T3/T4) was significantly associated with EFS. Xerostomia, hypothyroidism, dental caries, neck fibrosis, trismus, and dysphagia were the common late effects in survivors. Radiation myelitis was observed in one patient.

CONCLUSIONS

Treatment with neoadjuvant chemotherapy followed by concurrent chemoradiation provides good survival outcomes in pediatric NPC. The quality of life of the survivors is a pertinent area that necessitates consideration.

Extrapulmonary Small Cell Carcinoma - a Case Series of Oropharyngeal and Esophageal Primary Sites Treated with Chemo-Radiotherapy

BACKGROUND

The optimal sequence and extent of multimodality therapy remains to be defined for extrapulmonary small cell carcinoma because of its rarity. The purpose of our study was to assess the response to neoadjuvant chemotherapy followed by chemoradiation/radiation in patients with extrapulmonary small cell carcinoma.

MATERIALS AND METHODS

Four consecutively diagnosed patients were included in this study. The primary tumor site was oropharynx in three patients and esophagus in one. The patients with the limited disease were treated with chemotherapy followed by concurrent chemoradiation (n=2) or radiotherapy (n=1). The patient with the extensive disease with the primary site in vallecula was treated with chemotherapy and palliative radiotherapy to the metastatic site.

RESULTS

The median follow-up was 22.5 months (range, 8-24 months). Three patients with the limited disease (base of tongue, n=2; esophagus, n=1) were in complete remission. The patient with the extensive disease died of loco-regional tumor progression at 8 months from the time of diagnosis.

CONCLUSIONS

The combination of chemotherapy and radiotherapy is the preferred therapeutic approach for patients with extrapulmonary small cell carcinoma. Induction chemotherapy followed by concurrent chemoradiation or radiation provides a good loco-regional control in patients with limited disease.

Solitary fibrous tumor of the sellar region treated with adjuvant radiation therapy

The solitary fibrous tumor of central nervous system is rare. Herein, a case of solitary fibrous tumor arising from sellar region is described. A 60-year-old man underwent subtotal excision of the tumor because of extensive infiltration of optical and vascular structures. In view of the presence of residual tumor, he was treated with adjuvant radiation therapy. After a follow-up period of 1 year, there was no progression of the lesion evident on magnetic resonance imaging of the brain. Solitary fibrous tumor should be considered as one of the differential diagnosis of a mass lesion arising in sellar region. Immunohistochemistry with CD34 is valuable for discerning the diagnosis. Complete surgery should be the goal of treatment and adjuvant radiation therapy may be considered for residual or recurrent disease.

Synchronous malignant mixed Müllerian tumor of the uterus with transitional cell carcinoma of the ovary

A 55-year-old woman presented with a complaint of post-menopausal bleeding per vaginum. Local examination revealed a mass, protruding from the cervical os, which detached spontaneously. An adnexal mass was felt through the pouch of Douglas on per vaginum examination. Histopathological examination of the avulsed specimen revealed a diagnosis of malignant mixed Müllerian tumor. The patient underwent surgical staging with total abdominal hysterectomy, bilateral salpingo-oophorectomy, left pelvic lymphadenectomy, infracolic omentectomy, and peritoneal wash cytology. Pathological examination revealed a second primary tumor, that is, a transitional cell carcinoma of the ovary. Both the uterine malignant mixed Müllerian tumor and the ovarian transitional cell carcinoma were staged as IA. Subsequently, the patient was treated with adjuvant chemotherapy followed by radiotherapy. The patient is in complete remission at 1 year following the treatment. Synchronous genital tract neoplasms constitute a therapeutic challenge and necessitate an effective multimodality therapeutic approach based on meticulous pathological examination and tumor staging.

Treatment outcome of patients with carcinoma of vulva: experience from a tertiary cancer center of India

PURPOSE

The aim of our retrospective study was to analyze and report the clinical outcome of patients with vulvar carcinoma (VC) treated at our center.

MATERIALS AND METHODS

We retrieved the information regarding patients' clinical details, treatment given, survival and complications from the case records of all VC patients who were treated at our center during the year 1998-2005. Overall survival (OS) was determined with respect to age, histopathological grade, stage of disease, treatment group, pathological lymph node status, etc.

RESULTS

A total of 60 case records were retrieved for this retrospective analysis. Age ranged from 24 to 92 years (median 63 years). International Federation of Gynecology and Obstetrics (FIGO) stage distribution was as follows: stage I: 2 patients; stage II: 17 patients; stage III: 31 patients; stage IV: 9 patients; and unknown stage: 1 patient. Thirty-three patients underwent surgery (wide local excision 3, radical vulvectomy 30). Eleven patients received postoperative radiation therapy (PORT), 12 received palliative radiation therapy (RT) and 15 underwent definitive RT (5 of them received concurrent chemotherapy). Median follow-up period was 23 months (range 2-144 months). The 5-year OS for all stages was 41%. FIGO stage and pathological node positivity were found to be statistically significant prognostic factors for survival.

CONCLUSION

Despite the majority of patients presenting in advanced stage, the 5-year OS of 41% in our series reflects a decent therapeutic outcome. The results have shown FIGO stage and pathological node positivity to be significant prognostic factors for survival. The use of preoperative chemotherapy/RT needs to be studied in our setup.

Immunoreactivity with native zona pellucida of antibodies against a 19 amino acid synthetic peptide corresponding to human ZP3

Immunization of female Syrian hamsters with a 19mer-synthetic peptide corresponding to amino acid sequence 323-341 of human ZP3 and coupled to diphtheria toxoid (DT) led to generation of antibodies against both the peptide as well as DT. Antisera showed positive reaction in ELISA with solubilized isolated zona pellucida (SIZP) from human oocytes. In an indirect immunofluorescence assay, the anti-peptide antibodies bound to zona pellucida of human and bonnet monkey but failed to recognize that of mouse, rabbit, hamster and dog. These studies will help in designing a synthetic peptide based ZP immunocontraceptive vaccine for human application.

A vaccine that prevents pregnancy in women

We report here results of clinical trials on a birth control vaccine, consisting of a heterospecies dimer of the beta subunit of human chorionic gonadotropin (hCG) associated noncovalently with the alpha subunit of ovine luteinizing hormone and conjugated to tetanus and diphtheria toxoids as carriers, that induces antibodies of high avidity (K(a) approximately 10(10) M-1) against hCG. Fertile women exposed to conception over 1224 cycles recorded only one pregnancy at antibody titers of > 50 ng/ml (hCG bioneutralization capacity). The antibody response declines with time; fertility was regained when titers fell to < 35 ng/ml. This study presents evidence of the feasibility of a vaccine for control of human fertility.

Production and characterization of new murine monoclonal antibodies reactive to Mycobacterium tuberculosis

Murine monoclonal antibodies were raised against Mycobacterium tuberculosis (H37Rv) employing conventional hybridoma procedure. The binding characteristics of the four selected monoclonal antibodies reactive to M. tuberculosis were assessed by enzyme-linked immunosorbent assay (ELISA) using sonic extracts. The immunofluorescence test (IFT) was done using intact M. tuberculosis, 16 other mycobacterial species, and 10 bacteria of other genera. Monoclonal antibody A30 reacted strongly to M. tuberculosis both in ELISA and IFT. Monoclonal antibody A25 showed restricted cross-reactivity with mycobacterial species whereas two other monoclonal antibodies B6 and H2 appeared broadly cross-reactive. In Western blot analysis, A30 reacted with the 30-kD protein antigen, A25 with the 18- and 28-kD protein bands, H2 with the 18-kD antigen alone, and B6 with three bands of 17-19, 22, and 28 kD of M. tuberculosis H37Rv. A30 exhibited high reactivity with virulent M. tuberculosis H37Rv and a clinical South Indian Strain and minimal reactivity with avirulent M. tuberculosis H37Ra strain.